Subjective:

CC (Chief complaint): "This is ridiculous; I am missing my first period; do you want me to be late to my second class"?

HPI: A.C., a 44-year-old Asian female, was referred to the school EAP counselor by the principal of the school where she teaches for potential substance abuse. The principal hopes that some sort of intervention will be possible to facilitate getting her help and retain her as an employee. She arrived for the meeting and was noticeably upset about being called away from her class, which she was already late for. She was adamant that there was no way she had missed 22 days of being frequently late for her class. During the assessment, she pointed fingers, blaming the students and blaming her friends for why she was frequently late. She stated that the history department has frequent parties, and there is supplied alcohol; she also blamed the school hosting a monthly social hour on campus for why she drinks so much. During the interview, she also denied ever making her students copy notes from the bulletin board while she rested her head on her desk. When diving into information about her relationships, she hesitated to talk about them, became upset, and wanted to leave the interview. She finally admitted to drinking quite often, and she also stated that she has to drink to take the edge off. When asked to explain, she stated that the kids at the high school are "getting worse by the year." The teachers talk about it. "We all know what is going on. They become they just become more... more vicious, meaner.I am talking about kids who have no hint of remorse, no empathy, no thoughtfulness for others. She retired, "When was the last time you tried teaching them?" "Just last week, I caught Alexis filming me on her phone.I was bent over picking up trash a student threw on the floor.It was not flattering. And you know what she did?"She sent it out to the whole grade, adding a really obscene title." During the interview, Ally became very upset, and their tone increased. She was upset that the students basically got a slap on the wrist and never got into trouble when they should. She believes Principal Michales humiliated her by backing down the student's parents. She believes that she works for a place, a place that has no backbone and no spine. "Who runs this place here? The students or the teachers" "Rich kids who have no respect while you struggle to teach.I'm trying to pay bills here. Pay uh... pay the gas,driving a shitty car, pay off student loans" She admits that the build of all this stress causes her to drink, as she feels teachingno longer has any meaning. She admits that it takes 5 or 6 glasses of wine and a couple of mixed drinks to feel intoxicated. She admits that she drinks regularly, even when alone. She states that her father was an alcoholic during her childhood but that he found AA and got sober. She states that her mom was super supportive of her father but very strict about her drinking.

Past Psychiatric History: There is no history of any present or past psychiatric hospitalizations.

General statement: The patient was very evasive during the questioning phase of this interview and chose to point fingers at others for the reason she drinks.

Care Givers: -She has some friends in the history department where she works, but she lives alone. She shares custody of her 4-year-old son with her ex-husband. Although per the custody parenting plan, her son lives with his father.

Hospitalizations: She has never been hospitalized

Medication trials: There is no known information on any medication trials, psychiatric or otherwise.

Psychotherapy or Previous Psychiatric Diagnosis: She has never been diagnosed or seen by a psychiatric provider. There is no history of ever being diagnosed with any psychiatric diagnosis.

Substance Current Use and History: Admits to drinking, alone or socially, large amounts of alcohol on a weekly basis. She has had a history of drinking since prior to freshman year in high school, and it has increased more since. She obtained a DUI at age 21.

Family Psychiatric/Substance Use History: Mother and Father are still alive; she is an only child with no other siblings or close relatives.There is a history of alcoholism in her immediate family with her father. He was able to find AA and became sober. There is no other history of anyone in the immediate family with a known psychiatric diagnosis.

Psychosocial History: Ally grew up as an only child in Philadelphia, PA, with her mother and father. Her father drank much alcohol during her childhood. Her mother was supportive of him, and he was able to find AA and became sober. Ally obtained a PhD in Biology and a Masters in high school education (8-12). She is divorced and has a 4-year-old son living with his father.

Medical History:

• Current Medications:There are no current prescription medications, including over the counters being taken.
• Allergies: She has no known allergies to foods or medications.
• Reproductive Hx: Ally has one son, currently four years old

ROS:

GENERAL: No changes in weight. Has some fatigue from not sleepihaswell after drinking all night.

HEENT: No visual loss or double vision noted. No hearing loss or congestion, no runny nose or S/S of infection.

SKIN: Denies any rashes, sunburn, or itchiness.

CARDIOVASCULAR: Denies chest pains, tightness, palpitations, or edema.

RESPIRATORY: Denies any history of respiratory problems or shortness of breath.

GASTROINTESTINAL: Denies nausea, vomiting, constipation, diarrhea, anorexia, or abdominal pain.

GENITOURINARY: Denies pain during urination, increased urine frequency, hematuria, and urinary incontinence.

NEUROLOGICAL: Denies dizziness, headaches, tingling sensation in extremities, ataxia, memory problems, or paralysis and reported good bowel and bladder control.

MUSCULOSKELETAL: Denies muscle weakness, muscle pains, joint

pain, or loss of balance.

HEMATOLOGIC: Denies bleeding, blood transfusion, anemia, or bruising.

LYMPHATICS: No history of enlarged nodes or splenectomy.

ENDOCRINOLOGIC: Denies heat or cold intolerance, excessive sweating. Denies polyuria and polydipsia, or weight changes.

Objective:

General: There is some fatigue noted due to not sleeping well during the night. Her body movements and facial expressions show no signs of severe pain.

HEENT: Moist mucous membranes. No scleral icterus. No cervical lymphadenopathy.

Chest/Lung: Lungs are clear to auscultation bilaterally, with no accessory muscle.

Heart/Peripheral vascular: Heart tones are at a regular rate and rhythm. There is no murmur, no gallops or rubs. Pulses are 2+ bilaterally, with no bruit present. Carotid arteries have regular pulse bilaterally, and there is no edema in the lower extremities or clubbing of the fingernails.

Abdomen: The abdomen is soft and non-tender to palpitation; no distention or noted masses are noted. She is not guarding or protecting either side. Bowel sounds are present in all four quadrants.

Genital/rectal: No bladder distention. CVA suprapubic and present. She reports having a 4-year-old son.

Neurological: No focal neurological deficits. The Cranial nerves II-XII appear grossly intact but have not been individually tested.

Skin: Her skin is unremarkable; there are no signs of rashes or skin blemishes, and skin turgor is normal for her age.

Diagnostic results:

Physical exam

Assessment:

Mental Status Examination: A.C. is a 44-year-old Asian female who presents alone for psychiatric evaluation. She appears healthy, well-groomed, alert, and oriented to person, place, and time; she looks her stated age. During the interview, she had a lot of anger and irritability towards questions asked, which caused her to be defensive and evasive with her answers. She has good communication skills and was able to articulate her words well. She made judgments that it was other people's fault for why she drank so much. She reports that she feels unsafe and that the school does not consider her side around the high school students because they never get in trouble for what they do. She denies feeling suicidal with any thoughts or plans to hurt herself. She denies homicidal thoughts and has no history of hurting others. She also denies any hallucinations or delusions.

#1. Provide a minimum of three possible diagnoses with supporting evidence, listed in order from highest priority to lowest priority. Compare the DSM-5-TR diagnostic criteria for each differential diagnosis and explain what DSM-5-TR criteria rules out the differential diagnosis to find an accurate diagnosis. Explain the critical-thinking process that led you to the primary diagnosis you selected. Include pertinent positives and pertinent negatives for the specific patient case.

#2. Reflection notes:What would you do differently with this client if you could conduct the session over?Also include in your reflection a discussion related to legal/ethical considerations (demonstrate critical thinking beyond confidentiality and consent for treatment!), health promotion and disease prevention taking into consideration patient factors (such as age, ethnic group, etc.), PMH, and other risk factors (e.g., socioeconomic, cultural background, etc.).